Q&A NCCI Edits/CMS for Medicare and Medicaid - where for private insurance?

[Carol Viger]

Hi
I recently attended a meeting with the topic of NCCI edits. The subject matter demonstrated examples of how to use the CMS website for CPT codes to ensure clean claims but it went way too fast for a student.

Considering most payers follow CMS protocol, is there a way for a student to access portals with private insurance companies to learn their edits (eg, to ensure valid code pairs)? I have recently taken several assessment tests and I wish there was a way to have more assurance that my ICD's and CPT combinations were accurate before submitting them.

 

[Paul A]

I know some payers have such a tool for their contracted providers. I dont know if you need a separate log-on. I know the carrier i work for does not have such a tool. Mosts of our CCI edits are based on Medicare but there are many additional cutomized edits

 

[Carol Viger]

I know some payers have such a tool for their contracted providers. I dont know if you need a separate log-on. I know the carrier i work for does not have such a tool. Mosts of our CCI edits are based on Medicare but there are many additional cutomized edits

Thanks Paul! I have to presume that if this information were made public/more available, that it would open the door for fraud? ie, best to rely on coding guidelines, rather than referring to a recipe for what the payer will pay? As a student transitioning I am trying to find the logic of coding practice based on the real world, not my limited exposure. I recognize that as a public entity, CMS is obligated to provide information, but that viewpoint is possibly different from a payer point of view?

 

[Paul A]

I'm not certified or an experienced coder (Insurance background in provider relations, contract auditing) so probably dont have many of the answers but, worries of fraud, waste and abuse conccerns is probably one of the most of the reasons why alot of the informaton is not public. Even Medicare has some of their edits unpublished or just publish the most obvious. One of the biggest things at my company is those billers who modify their coding on what will get paid, not what is proper coding.

What really got made me think about it is when someone asked me (thinking I was further in my studies than i am) if a code combo was payabe, I looked in CPT book which said yes. The coder i deferred it to ran it through the claim check software and it was not separately reimbursable. Just becaue its searately reimbursable per CPT does not mean it will be paid, nor does existence of a CPT code make it a covered benefit, etc.

I know some carriers will have different rules on how to report things like bilaterial on a single line with 1 unit and mod 50 or each side of a body on a separate line with RT and LT mod. Report the colonoscopy by deepest the scope went vs what was was actually planned. Or bill as observation even if it was inpatient but only authorized as Obs. However, to me, it seems its best just to follow CPT guidelines and report things properly even if the insurance decides in the end they dont want to pay more.